The long reach of war's costs: building the evidence for action
Authors: Eran Bendavid
Journal: The Lancet Global Health (2023)

Karl Popper's notion of falsification in scientific discovery remains influential nearly 100 years after its formulation.1Popper KR The logic of scientific discovery.Rev. ed. Harper & Row, New York, NY1934Google Scholar The Popperian view of scientific progress posits that theories gain strength by being open to falsification, and at the same time remaining consistent with observed data time and again. This process is how we come to consider scientific theories as representing reality: we posit them in ways that can be empirically confirmed or disconfirmed, we repeatedly test them against observation, and we do not find them false. Why is the theory, smoking increases risk of lung cancer stronger than radiation from a CT scan increases risk of lung cancer? The former has withstood Popperian tests many times, consistently, and by different groups. The latter has not. In this issue of the Lancet Global Health, Felix Amberg and colleagues2Amberg F Chansa C Niangaly H Sankoh O De Allegri M Examining the relationship between armed conflict and coverage of maternal and child health services in 35 countries in sub-Saharan Africa: a geospatial analysis.Lancet Glob Health. 2023; 11: e843-e853Summary Full Text Full Text PDF Scopus (1) Google Scholar publish a study that furthers another theory: armed conflict is population health improvement in reverse. This paper is a textbook contribution to growing this scientific theory. Why so? First, the Article adds to an increasing body of literature on this topic.3Wagner Z Heft-Neal S Bhutta ZA Black RE Burke M Bendavid E Armed conflict and child mortality in Africa: a geospatial analysis.Lancet. 2018; 392: 857-865Summary Full Text Full Text PDF PubMed Scopus (78) Google Scholar, 4Wagner Z Heft-Neal S Wise PH et al.Women and children living in areas of armed conflict in Africa: a geospatial analysis of mortality and orphanhood.Lancet Glob Health. 2019; 7: e1622-e1631Summary Full Text Full Text PDF PubMed Scopus (39) Google Scholar, 5Kotsadam A Østby G Armed conflict and maternal mortality: a micro-level analysis of sub-Saharan Africa, 1989–2013.Soc Sci Med. 2019; 239112526Crossref PubMed Scopus (24) Google Scholar Increasingly, studies on the population health effects of armed conflicts examine large amounts of evidence quantitatively, adding rigor and scale to older descriptive and qualitative studies. Second, the design of the study is sufficiently strong that alternative theories to explain the observed evidence are less likely. Third, this study comes from a group examining this issue afresh. And fourth, the theory underlying the study has intuitive appeal—the burden of the evidence is not as high as might be needed to support an unusual notion. The study by Amberg and colleagues2Amberg F Chansa C Niangaly H Sankoh O De Allegri M Examining the relationship between armed conflict and coverage of maternal and child health services in 35 countries in sub-Saharan Africa: a geospatial analysis.Lancet Glob Health. 2023; 11: e843-e853Summary Full Text Full Text PDF Scopus (1) Google Scholar deserves special credit for its design. The fundamental question the investigators ask—does armed conflict compromise health service provision for mothers and young children—is hard to address. For one, trials or prospective cohorts tackling this question are not feasible: armed conflict is not an intervention, and its eruption prevents data collection. So how does this study generate such strong evidence under these circumstances? It's a combination of data and design. The investigators link two datasets: one on the location, timing, and intensity of armed conflict events (ie, the Uppsala Conflict Data Program Georeferenced Events Dataset, or UCDP GED) and the other being the Demographic and Health Survey (DHS). Much has been said about the DHS. From the standpoint of understanding global health epidemiology and context, the DHS has been one of a kind: the same core survey, carried out for more than 40 years, executed well in many low-income countries, and provided largely free of charge to anyone interested in improving the lives of those in low-income and middle-income countries. The investigators link conflict location with place of residence of DHS respondents. That's the key to success. Next, small areas in the 35 countries are re-imagined as their own prospective cohort, which is enabled by the data. Nearly 3500 of these small cohorts are examined, and the outcomes for each pregnancy or birth are noted. Conflict events erupt in some of these cohorts. The statistical models then ask: on average, in these cohorts, what is the likelihood of receiving care following conflict eruption relative to times without conflict? That's the key estimation. It cannot tell us if the conflict caused the change in health services. Such causal attribution is a hard task even in randomised controlled trials, but here's the causal magic of this study design. Another factor other than conflict could have caused these changes, but this other cause would have to overlap with conflict in space and time. Coming up with such alternative causes is not impossible: extreme heat might increase the likelihood of conflict and might retard health service provision; local economic depression might predispose an area to conflict and might hinder health system functioning. The strength of this kind of design is not the elimination of alternative explanations, but narrowing the field of alternative candidates, thus upweighting the likelihood of the most plausible cause. A large number of scientific studies in medicine and epidemiology do not support—indeed, sometimes contradict—established theories.6Ioannidis JP Contradicted and initially stronger effects in highly cited clinical research.JAMA. 2005; 294: 218-228Crossref PubMed Scopus (1082) Google Scholar, 7Ioannidis JP Why most published research findings are false.PLoS Med. 2005; 2: e124Crossref PubMed Scopus (5989) Google Scholar Such scientific reversals can happen more often when theories are implausible, when issues of selection or bias are hard to overcome, or when other interests get in the way of the scientific process. Therefore, when the theory being probed is plausible, when the design of the study is strong, when the investigators are independent, and when the results are congruent, the study is reassuring. Now that research about the deleterious health effects of conflict is increasingly reliable, what are we to do with this knowledge? For better or worse, the armed conflict between Russia and Ukraine has raised the public prominence of these issues. Without diminishing the importance of the Russia–Ukraine conflict, studies such as Amberg and colleagues' serve as a reminder that armed conflict remains widespread, especially in sub-Saharan Africa and Asia, and that the populations affected suffer well beyond the immediate and highly visible effects. The global health community can—and should—call for fewer armed conflicts, even if it does not typically engage with peacekeeping or diplomacy to reduce future conflicts. However, mitigating the long-lasting consequences of armed conflict Amberg and colleagues discuss supporting health services and ensuring the supply of health provisions for mothers and children, which is a core strength of the global health community. And the evidence can support such action. I declare no competing interests. Examining the relationship between armed conflict and coverage of maternal and child health services in 35 countries in sub-Saharan Africa: a geospatial analysisOur findings suggest that health service coverage is significantly affected by contemporaneous conflict, but health systems can adapt to provide routine services, such as child curative services, in situations of prolonged conflict. Our analysis underlines the importance of studying health service coverage during conflict both at the finest possible scales and across different indicators, pointing at the need for differential policy interventions. Full-Text PDF Open Access